WILTIMS #272-6: Music and a match day

This post is almost a week late, but it's finally here! I will hopefully have another big post for this week in the next couple days. Apologies for my tardiness and, as always, please comment if you have any questions!

Sunday: Over the weekend I went to a classical music concert at another nearby medical school with one of my professors (renowned for his beat-boxed heart sounds) conducting an entire orchestra composed of members of the medical field. Two of my classmates made up half the cello section! It was a really good concert and a nice reminder that not everyone in medicine needs to be a one-dimensional diagnostic robot. Also, we joked that this is one of the few orchestras where it is totally excusable for one of the musicians to need to answer a phone call in the middle of the concert. Several of the doctors in the string section had to answer pages during intermission.

MondayIL: The obturator and psoas signs are diagnostic movements that can be done by the patient to test for appendicitis. These tests work by manipulating muscles in the abdomen to tug on the peritoneum (the sac surrounding most abdominal organs) which is inflamed and will exhibit pain when irritated. These tests look kinda weird though because you stretch and contract these muscles by moving your legs. Yet another example of doctors looking crazy but having a reason. "Your stomach hurts? Well move your right leg for me..."

Ruptured esophageal varices is one of those conditions that is really terrible to treat. These varices (think varicose veins... 'cause that's exactly what they are) are a ballooning of the veins in the lower esophagus due to pressure build up throughout the portal blood system, usually due to liver disease such as alcoholic cirrhosis. The problem is that these veins are prone to rupturing and bleeding into the GI tract. Normally the body would work to clot the blood and stop the bleeding, but since the liver is failing it can't produce the protein clotting factors in the blood. At the same time, the patient is already anemic from blood pooling and lysing in the enlarged spleen thanks to that same portal hypertension that caused the varices to begin with. If you try to give the patient blood, it will just bleed back out again into the GI tract, but if you don't give them blood, they'll die of hypovolemic shock. And your stomach doesn't like blood, so the patient will often be vomiting blood throughout this process and care must be taken that none of it comes back down the wrong pipe or they'll drown in their own blood. Remember the underlying cause of all of this? Alcohol damaging the liver. Please drink responsibly.

TuesdayIL: "Acute abdomen" is a really dumb term that essentially means that surgery needs to be involved, right now. It's just a vague term for any of the numerous conditions that must be quickly ruled out when someone presents to the ER or doctors office with sudden, severe abdominal pain. If one of these conditions is suspected, then it is an emergency and exploratory surgery is often done to both confirm what the specific problem is and hopefully treat it. But since a specific diagnosis isn't necessarily know at that point, we just use acute abdomen as a placeholder.

WednesdayIL: Cholecystitis, an inflamed gall bladder, has a nifty if not entirely PC mnemonic for remembering who is most at risk - the Four Fs: forty fat female and fertile.

ThursdayIL: Alcoholics Anonymous is really religious, but kinda passive-aggressively inclusive at the same time. We had a presentation by a few local leaders of an AA group, where they held an open meeting and shared their stories. And boy were they compelling stories. We were also given a printout of the 12 steps, which I had not read before. I was surprised at how prominently "God" is mentioned throughout the steps, but after hearing one atheist's journey to sobriety and finding a personal definition of God, I was much less concerned about any conflict of sending a non-religious patient to their services.  Though I have seen articles about the lack of any robust evidence that AA is the best treatment for alcoholics, I think I would be supportive of recommending that patients give them a try. I'll take as many tools as I can get.

FridayIL: Match Day is tense and emotional to watch in person. Friday was the day that nearly all the 4th year medical students in the country find out where our algorithmic overlords have contractually sent them for the next 3-5 years. I have in the past watched all sorts of videos of other schools' Match Day proceedings. Many do a big simultaneous opening of the envelopes to add to the drama. There's always a hushed silence as paper is shredded and the soon to be MDs speed read the letter to see if they got their first choice. Then there are screams of happiness, hugs and tears - most of joy, some of disappointment. The rest of the day is a big celebration with everyone running around to see where their friends will be going. The school posts the match list in the hallways and us lowerclassmen creep out of our study holes to ogle the achievements of our fellow students. T minus 2 years until that's me. Yikes!

WILTIMS #267-71: GI Mega-Post!

MondayIL: FODMAP is an oft-used acronym for the avoidable dietary causes of GI discomfort.
Fermentable Oligo-, Di- and Monosaccharides And Polyols (in english: carbs, sugars and a special type of alcohol)

TuesdayIL: Severe burns can cause acute gastritis. You might rightly wonder how hurting your skin affects your stomach. The main complication of severe burns is a loss of fluid leading to hypotension. This lack of blood causes hypoxia and ischemia of the mucosal layer of the stomach (among many other effects), leading to decreased mucus production and increased acid damage to the stomach lining.

Phrase of the day: Catastrophic exsanguination - n. the act of bleeding out.

WednesdayIL: Ecstasy, LSD and similar drugs aren't really addictive substances because they don't mess with our reward centers or neurotransmitters that make you happy. They generally just cause hallucinations which, though interesting, just get old and/or too freaky after a while. They're still dangerous and can be abused, they just have limited addiction potential.

Alcohol increases sexual desire (by removing inhibitions) but decreases physiological response to said desires. "It can be less than, you know, a compelling experience that one would hope for, I guess you could say. [chuckles]" ~our pharmacology professor

ThursdayIL: Inflammatory pseudopolyps associated with irritable bowel disease look like the worm-creatures cursed by Ursula in The Little Mermaid. No? Just me?

FridayIL: Yerba mate is an Argentinean tea that's drunk fresh (i.e. still boiling) with a metal straw, causing thermal injury that can result in a higher risk of Barrett's esophagus. Barrett's esophagus is a fairly common condition where the bottom of the esophagus undergoes metaplasia due to chronic irritation, usually from GERD.

Quote of the day: "You can always get a new GI fellow, you can't get a new scope. Don't drop the scope." ~ Director of Liver Transplantation

The pancreas sucks. Besides having the worst cancer, pancreatic inflammation can easily kill you. The best analogy I could come up with to explain why is that the pancreas is like the gas tank in your car. A gas tank holds a relatively dangerous substance that is mixed with fire to create a controlled explosion in the engine. The pancreas holds enzymes that are activated in the gut to digest food. If those enzymes are activated early (throw a match in the gas tank) then they digest the pancreas which, just like the rest of the body, is made of the same building blocks as the food we eat. The pancreas effectively explodes. This releases these enzymes into the retroperitoneal space of the abdomen where the enzymes start digesting anything it comes in contact with: the liver, the kidneys, the intestines, etc. There is nothing we can do for this. The treatment is to give IV fluids and pain meds and hope the patient recovers.

Source: http://insidesurgery.com/

Pancreaticojejunostomy is a crazy procedure used to treat chronic pancreatitis. In order to drain the dangerous secretions from the pancreas, the small intestine is bisected and part of it is used to create a new duct that goes straight from the pancreas to the GI tract.

WILTIMS #266: Just a taste

What!? A one-off daily post?! Surely such a thing is not done anymore!

Well here it is, but just so you don't die of shock, it's still a day late. And don't call me Shirley.

This week was just the right length: half a day. Between study days, exam day, and a snow day there wasn't much time for actual class. We started gastrointestinal pathology/pharmacology on Friday which has already proved to be one of the grosser looking pathology sections. Mmm fatty, bloody ulcers! Amusing that the organ system in charge of eating is the one that makes me not want to...

YesterdayIL: Several antipsychotic drugs can be used as antiemetics (anti-nausea/vomiting medications) but you get all the nasty side effects, so they are usually not your first choice.

There is a relatively common congenital abnormality known as tracheoesophageal fistula where the esophagus doesn't form correctly and instead comes off the trachea. The vast majority of cases have a particular arrangement where the esophagus dead-ends right after splitting off from the trachea and then the lower esophagus connects to the respiratory tract near the branching of the main bronchi. Nearly every other connection combination is possible, but all are far less likely. All of these are discovered very quickly and, assuming nothing terrible happens first (like the baby aspirating food and developing pneumonia), it is easily surgically corrected.

Type C is the most common. source

Schatzki's ring is a pathological finding that is seen with a chronic sliding hernia of the stomach up through the diaphragm. In case you, like me prior to med school, don't exactly know what a hernia is: a hernia is any condition where part of an organ protrudes through the cavity containing it. Some types you may have heard of are an inguinal hernia, where intestine escapes into the groin area; an umbilical hernia, where the intestine pushes through the relatively weak area around the belly-button (umbilicus); and a hiatal hernia, where the stomach slides up through the diagram... which can cause scarring and a Schatzki's ring! Woo, made it back around!

WILTIMS #261-5: Renal wrap-up with a side of death and vodka

Another week, another pre-exam post! This was a tiny block of material compared to the last couple, but boy have the kidneys made up for it with complexity. And just to make things more interesting, we also threw autoimmune/connective tissue diseases into the mix. The upshot of those is lupus can cause anything. There. See? Now you know as much as I do! erm... I mean, I totally know more stuff grumbleantiDSgrumblerheumaticgrumbleSmithgrumbleSjogren's...

Anyways, here's a thingy I made for brushing up on the basics of renal physiology and pharmacology:

Click to enlarge

Simple right!? In all honesty, even though it's super complicated, I love learning about the kidneys. They do incredibly important things with an efficiency and precision that's astounding. Of course they also like to freak out and kill you when they get confused, but that's fun too, in its way.

Heart: Ugh, I just can't do it! I can't take any more blood pressure...
Kidneys: What's that Heart? More blood pressure? We've got your back!
Heart: What? No! I'm already exhausted why would I want more blood pressure!?
Kidneys: Even, more!? Wow!
Heart: NOOO!
Kidneys: WE'RE HELPING!

MondayIL: The title coroner originally meant a representative of the King (hence the corona root) whose job was to make sure a person was truly dead, because at death all debts return to the crown. Being "dead" was a great way to dodge your debt.

One of the few interesting things to come out of an optional talk I went to this evening was a great analogy about the murkiness of defining death: defining death is like defining blindness. You can be legally blind while still being able to perceive light. The point of the definition is that beyond some threshold, one's eyes are no longer able to do that which gives them purpose. Similarly, you can be legally dead without having lost all of your bodily functions. But is a beating heart or breathing lungs lying on a bed really a person by any meaningful definition?

TuesdayIL: Autosomal dominant polycystic kidney disease makes for some HUGE kidneys. Today was a gross specimen review and there was one set of kidneys that we jokingly said we would have believed was a brain or lung, had it been labeled so.

WednesdayIL: If you try to poison someone with ethylene glycol (antifreeze) you'll get caught on autopsy when they find calcium oxalate crystals in the kidney. Oxalic acid is one of the breakdown products of antifreeze and, while the poison's trying to kill you, the kidneys try to filter it. As the urine gets more concentrated with the oxalate, it forms very specific kidney stones which, you'll remember from the other day, look like letter envelopes. Counteracting this type of poisoning is also one of the few instances where giving IV ethanol (yep, think the world's purest vodka straight into your veins) is an acceptable treatment. The alcohol blocks the enzyme that breaks ethylene glycol down into its poisonous byproducts, giving the body more time to filter all of these chemicals out of the blood. So if you're poisoned, the drinks are on us!

Thursday I Learned: that I do, in fact, know some things! Today was another four-month checkup with my oncologist. (All is well, by the way.) While I was there, the doctor was interrupted by a nurse, who was asking what the reason was for admitting another patient to the hospital. "Her hemoglobin is 5..." he said, a little incredulously, before rewording it in a way that a hospital would approve of. As he turned back to me, he saw my eyebrow-raised expression, and chuckled. "You know how bad that is now, don't you?"

It's the little things that remind me that I am actually making progress.

Friday: Today we had a small-group case study that was based on a tragic real-life case of deadly misdiagnosis. That sounds rather depressing, but because we are highlighting it, 200 soon to be doctors won't ever make that same error. Mistakes happen all the time in medicine; we're only human. But we can honor the people we harm, by learning and teaching about the mistakes we make.

The mistake in question: A slightly elevated creatinine level on a petite female is indicative of much worse renal/urinary problems than a simple UTI.

FridayIL: How to sign "Where does it hurt?"

http://www.lifeprint.com/

WILTIMS #257-260: To pee or not to pee

TuesdayIL: Although antinuclear antibody (ANA) is very sensitive for lupus, it's not even remotely specific. Biostats translation: If this test is negative, you definitely don't have lupus; if it's positive, you have something, but it may or may not be lupus. Anti-double stranded DNA and anti-Sm tests are much more specific, but less sensitive (if positive, you definitely have lupus, but if negative, you may or may not).

Wednesday: Today we started one of our less intensive courses, Medical Ethics II. Ethics I, which we took last year, consisted mostly of us debating hypothetical medical dilemmas and learning about the balance between concepts like autonomy, justice, beneficence, and nonmaleficence. This year is simpler in that there is only one topic and yet more complicated in that it's death. Ought to be fun!

WednesdayIL: Rheumatoid arthritis is diagnosed by a complicated scoring algorithm involving counting the the number of affected joints, positive blood tests, and the duration of the symptoms.

ThursdayIL: Urine is usually darker when it's more concentrated, the excepting being in diabetes, where the urine is extremely clear but absolutely full of sugar.

Without having other data with which to compare, there is no normal urine pH. But it's still an incredibly useful number. For the chemistry buffs out there: since there is no good pH indicator that covers the broad range of pHs urine can be found at, they actually use a mix of two pH indicators to test urine pH. A problem with this is that one of the indicators also responds to protein content (which is normally not present in urine). So, if a patient has proteinuria, you cannot rely on the normal indicator blend to determine pH.

Can you match the crystals with their descriptions of the left?
The yellow panel is uric acid, which I did not mention because it's boring.

Urine can precipitate many types of crystals. Triple phosphate (aka struvite) crystals have a coffin lid appearance. Cysteine crystals are hexagonal. Calcium oxalate crystals are bipyramidal or "envelope-like", depending on if you think in 3 or 2 dimensions.

FridayIL: Secreting acid in the urine is hard. We have pumps in the collecting ducts of the kidney that can directly excrete hydrogen ions, the problem with this is that it very quickly acidifies the urine to a pH similar to your stomach acid. You would quite literally digest your kidney.

So how do you excrete acid without making the urine too acidic? Buffers! Phosphate combines with hydrogen ions to form phosphoric acid*, which is far less acidic than the hydrochloric acid that would otherwise be formed. The phosphate is largely derived from the bones, which is why long term acidosis can cause osteoporosis. Ammonia is also used as a conjugate base to form ammonium, another weak acid.

*This is all way more complicated thanks to phosphoric acid being triprotic. For the chemistry sticklers out there: various conjugates (HPO₄^-2, H₂PO₄^-1) are used as the phosphate ion moves through different pH environments.

WILTIMS #253-6: I kidney you not

Heart -check, lungs -check, brain -check! On to the next organ: kidneys! Compared with the previous three, the poor kidneys get no respect. But when things go wrong for your determined little blood filterers, you'll notice ...and/or die. 

Tuesday: I had a preceptor visit today where I had my first experience with an interpreter. I'm actually amazed that it took this long! Last year, the doctors I worked with were both fluent in a several languages and mostly cherry-picked the english-speaking patients for me, so they wouldn't have to play both doctor and interpreter.

Today's patient was a ~80 year old woman who came in with her grandson. The patient spoke no english at all but her grandson was extremely well spoken. I quickly saw, as we were warned in our FCM class, that a using a family member as an interpreter could be dangerous if you don't trust the interpretation or motives. Even something as innocuous as "I'm sure what she means is..." can dramatically change the narrative you're hearing from a patient and the clinical picture you base medical decisions on.

This particular interview went surprisingly well and I think I was able to get nearly all the information I wanted. Figuring out the type of pain being felt was particularly difficult. It wasn't sharp, dull, stabbing... and whatever the word was she saying didn't quite translate. We eventually settled on "tingling," which matched the our physical exam findings of nerve-associated dysfunction.

TuesdayIL: There are two broad syndromes of renal dysfunction and they are super-helpfully named: nephritic and nephrotic syndromes. Nephritic patients will have blood in the urine (hematuria), protein in the urine (proteinuria), high blood pressure, and a low urine volume. Nephrotic syndrome, by comparison, is markedly more severe proteinuria, low blood albumin levels (hypoalbuminemia), generalized swelling (edema), and high blood lipid levels (hyperlipidemia). Simple, right? And these are just broad categories that each specific renal disease shares some combination of features with.

WednesdayIL: Red blood cells should never be in the urine, but their morphology, when present, can hint at where the bleeding is happening. Crinkly red blood cells in the urine typically come from the upper urinary tract or kidney. This is might relate to the multiple changes in concentration and/or just being in the urine for a longer time. Normal looking red blood cells generally come from lower, in the ureters, bladder or urethra.

ThursdayIL: Foamy urine is indicative of severe proteinuria.

FridayIL: The indications for dialysis can be remembered by the mnemonic AEIOU:

Acidosis (low blood pH)
Electrolytes (ion imbalances)
Intoxication/Ingestion (toxic substances)
Overload of fluid
Uremia (severe blood loss through the urine)

WILTIMS #249-252: Neuro wrap-up

Sorry again for the dearth of posts. The first exams of the new term are on Monday (barring a fantastically well-timed potential snowstorm), so learning took precedent over writing about learning. So, without further ado:

FridayIL: Morphine has the same high potential for abuse as other strong opiod medications like oxycodone. The reason you don't hear about rampant morphine addiction is that morphine undergoes extensive first pass metabolism in the liver. If a drug is taken orally, it's absorbed in the GI tract and passes through the liver en route to the rest of the body. The liver detoxifies our blood and if its enzymes are able to breakdown a drug, the amount of drug available to have an effect on the body is dramatically reduced. So, though morphine is the active ingredient in opium and is the breakdown product of other drugs like codeine, it isn't typically abused itself since it can't be effectively given orally.

Monday: SNOW DAY!

TuesdayIL: Ketamine is a N-methyl-D-aspartate (NMDA) receptor antagonist used as a chemical restraint. It is part of a class of drugs called dissociative anesthetics because people under their effects are "dissociated" from the world.

WednesdayIL: Louis Pasteur created the first rabies vaccine by blending up the spinal cord of rabbits infected with rabies.

Osmotic demyelination syndrome (aka central pontine myelinolysis) sucks. This is a form of brain damage caused by too rapidly correcting hyponatremia (low sodium). This scenario usually unfolds as an ER doctor treating a chronic alcoholic and accidentally causing permanent paralysis, locked-in syndrome or death.

Marchiafava-Bignami disease is necrosis of the central third of the corpus callosum caused by drinking crappy red wine. It's probably not actually due to the wine (which was noted in the first described cases in Italy) but the associated vitamin deficiencies seen in chronic alcoholics. So always drink in moderation and, just to be safe, drink good wine. (Not quite) doctor's orders!

Germinal matrix hemorrhage is a common brain injury found in severely premature infants. The brain is normally very good at regulating the volume of blood in its vessels. If the brain vasculature is not fully developed, the sudden increase in blood pressure when the placenta is cut off (no pun intended) from the peripheral circulation can cause the brain blood vessels to burst.

TIL: ...a wonderfully inappropriate mnemonic (aren't all the best ones?) for the structures of the cerebellum:

Lovers can't cum? Don't fret! Try prayer, U novice.

Cerebellar structures: Lingula, culmen, cline, decline, folium, trigone, pulvinar, uvula, nodulus.